肝功能化验异常的分析与解释

1肝功能化验异常的分析与解释赵新颜2肝脏具有那些功能?代谢功能胆汁生成和排泄凝血功能解毒作用3肝脏分类检测Enzymetests–Aminotransferases–Alkalinephosphatase–Gammaglutamyltranspeptidase•Testsofsyntheticfunction–Albumin–Prothrombintime•Testsofhepatictransportcapability–Serumbilirubin4丙氨酸氨基转移酶AlanineAminotransferase(ALT)SerumGlutamic-pyruvicTransaminase(SGPT)组织来源:肝细胞胞浆丙氨酸α酮戊二酸丙酮酸谷氨酸5天冬氨酸氨基转移酶AspartateAminotransferase(AST)SerumGlutamic-oxaloaceticTransaminase(SGOT)组织来源:心脏,肌肉,肾脏,脑,胰腺,红细胞肝细胞胞浆(20%)及线粒体(80%)天门冬氨酸α酮戊二酸草酰乙酸谷氨酸AST6ALT与ASTSevere(20times,1000U/L)急性病毒性肝炎,药物或毒物损伤,休克肝Moderate(3-20times)慢性肝炎,药物性肝炎,酒精性肝炎,自身免疫性肝炎…Mild(1-3times)脂肪肝,非酒精性脂肪性肝炎,肝硬化7ALT:ASTratioAST：ALT≥2酒精性肝病AST：ALT1肝硬化8碱性磷酸酶AlkalinePhosphatase(ALP)组织来源:肝脏,骨骼,肠道,胎盘机制:胆汁酸增加ALP脂溶性,刺激ALP合成9碱性磷酸酶AlkalinePhosphatase(ALP)意义:肝脏相关的:肝内胆汁淤积部分或完全胆道梗阻肝脏肿瘤肉芽肿性病变非肝脏因素:骨肿瘤妊娠10谷酰转肽酶Gamma-glutamyltransferase(GGT)组织来源:membraneofcells(liver,kidney,pancreas,intestine,prostate)意义:胆汁淤积原发性或转移性肝癌酒精性肝病胰腺癌,壶腹周围癌11肝功能异常类型化验肝细胞损伤胆汁淤积转氨酶8倍正常值3倍正常值ALP3倍正常值8倍正常值BIL增高增高PT延长，对维生素K治疗反应差延长，对维生素K治疗反应好腹痛不常见常见（肝外梗阻时）发热，WBC增高不常见常见（肝外梗阻时）12胆红素代谢示意图13胆红素Bilirubin(BIL)间接胆红素增高血症:生成过多肝脏摄取受损葡萄糖醛酸化受损14间接胆红素增高血症(例1)李霞，女，27岁非洲工作（08-4-18至08-10-7）稽留热5天（08-10-18至08-10-22）血图片：可见疟原虫（外院）服用氯奎3日，青蒿琥酯片及蒿甲醚5日热退（08-10-20至08-10-27）入院前3日再次高热伴阵发中上腹绞痛（08-10-28）血色素9.1g/dl降至3.9g/dl伴酱油色尿，网织红2.53%ALT30U/L,AST57U/L,TBIL40.3umol/L,IBIL27.43umol/L,LDH863U/L15间接胆红素增高血症(例2)中年女性。胆结石拟手术，发现间接胆红素增高请会诊。Hb正常网织红细胞比例增高。外周血图片16间接胆红素增高血症(例3)刘壮飞，男性，12岁反复皮肤黄染伴乏力6年父亲自18岁起发现胆红素升高，以间接胆红素为主ALT16U/L，AST27U/L正常TBIL46.2umol/L，IBIL30.0umol/L。组织病理学最终诊断：Gilbert综合征17胆红素Bilirubin(BIL)直接胆红素增高血症:肝外胆管梗阻肝内胆汁淤积18肝外胆管梗阻李彦红，女性，77岁突然皮肤巩膜黄染10天ALT，AST正常ALP302U/L，GGT361U/LTBIL250.60umol/L,DBIL233.60umol/L19肝外胆管梗阻20正常胰胆管系统21胆汁分泌障碍、流速减慢或停滞，可发生在从肝细胞、毛细胆管直至Vater壶腹各水平。临床：以瘙痒、黄疸、ALP、GGT增高等为特征。病理：肝细胞及/或胆道系统胆汁成分蓄积。肝内胆汁淤积的概念22肝内各级胆管及其命名Hering管总胆管右肝管左肝管400-800um段胆管300-400um区胆管100um隔胆管15-100um叶间小胆管15um细胆管毛细胆管肝细胞23肝内毛细胆管—小叶间胆管ductuleBilecanaliculus自ScheuerPJ，LiveBiopsyInterpretation.2006，5324肝内胆汁淤积–Viralhepatitis–Etohhepatitis–EBV,CMV–Anabolic,steroids,Contraceptives,TPN–Primarybiliarysclerosis–Primarysclerosingcholangitis25肝内胆汁淤积26肝内胆汁淤积27肝内胆汁淤积28＋甘氨酸，牛磺酸总胆汁酸TBA2930肝脏合成功能白蛋白MalnutritionNephroticsyndromeProteinlosingenteropathy(Sprue,Crohn’s)凝血酶原活动度60%40~60%40%胆碱脂酶31胆碱脂酶Acetylcholinesterase真性胆碱脂酶红细胞和脑灰质运动神经节终板有机磷中毒假性胆碱酶（拟胆碱脂酶）肝脏合成反应肝功能储备孕妇及口服避孕药可降低32肝功能储备Child-Pugh1分2分3分白蛋白g/dL3.52.8-3.52.8PT延长秒1-34-66胆红素mg/dl≤22-33腹水无少量中量肝性脑病无1~23~4GradeA1-6;GradeB7-9;GradeC10~15ChildCG,TurcotteJG.Surgeryandportalhypertension.In:Theliverandportalhypertension.EditedbyCGChild.Philadelphia:Saunders1964:50-64.PughRN,Murray-LyonIM,DawsonJL,PietroniMC,WilliamsR(1973).TheBritishjournalofsurgery60(8):646–9.33肝功能储备Child-PughPointsClassOneyearsurvival(%)Twoyearsurvival(%)5-6A100857-9B815710-15C453534肝功能储备MELDTheModelforEnd-StageLiverDiseaseMELD=3.78[Lnserumbilirubin(mg/dL)]+11.2[LnINR]+9.57[Lnserumcreatinine(mg/dL)]+6.43Interpretation(3month)40ormore-100%mortality30-39-83%mortality20-29-76%mortality10-19-27%mortality10-4%mortalityMalinchocM,KamathPS,GordonFD,etal.(April2000).Hepatology31(4):864–71.35女性，54岁主诉：上腹不适、恶心2天入院日期：2008－08－21高球蛋白血症36治疗前后肝功能ALTASTALPGGTALBGLOCHETBILDBIL08-2080470531.872.481.1161.0108-2251545013329126.3743.2680.3862.0908-28155931433432362.73.2231.3524.0809-03907916135222.564.33.1737.4727.0609-10(↑)9711219336322.462.42.9547.9434.2609-16706519238924.164.53.3326.5117.9209-2412811418344432.867.84.5144.3625.7710-21458913640230.164.84.926.6915.0910-15584210725231.854.65.1516.7937高球蛋白血症中年女性,急性起病.转氨酶显著增高,轻度黄疸.明显高球蛋白血症.ANA阳性.肝组织病理学符合自身免疫性肝炎的表现.激素治疗基本有效!38Globulinisoneofthetwotypesofserumproteins,theotherbeingalbumin.Proteinelectrophoresis:Alpha1globulinsAlpha2globulinsBetaglobulinsGammaglobulins(onegroupofgammaglobulinsareimmunoglobulins,thatfunctionasantibodies)Globulin39HyperglobulinemiaHyperglobulinemia:PolyclonalGammopathyChronicbacterialdiseases•PneumoniaChronicfungaldiseasesChronicprotozoal原虫的/rickettsialdiseases40HyperglobulinemiaHyperglobulinemia:PolyclonalGammopathyChronicviraldiseasesNeoplasia•Lymphoma•Mastcelltumor•OthertumorsAutoimmunedisorders•Systemiclupuserythematosus•Chronicpolyarthritis•Others41HyperglobulinemiaHyperglobulinemia:MonoclonalGammopathyNeoplasia•Multiplemyeloma•Lymphoma•ChroniclymphocyticleukemiaInflammation/infection•LeishmaniasisIdiopathic•Waldenstrommacroglobulinemia•Benignmonoclonalgammopathy42SerumProteinElectrophoresis--NormalPattern43SerumProteinElectrophoresis--PolyclonalGammopathysarcordosisThesequentialincreaseoftheglobulinfractionsillustratedsarcoidstepping.44SerumProteinElectrophoresis--NephroticPatternalpha-2-macroglobulinLossoflowermolecularweightproteins(Examples:albumin,IgG)Retentionofhighermolecularweightproteins(examplealpha-2-macroglobulin.)SLE45SerumProteinElectrophoresis--CirrhoticPatternbeta-gammabridgepatternendstageliverdiseasesecondarytochronicalcoholabuse46SerumProteinElectrophoresis--Acuteinflammatorypatternpneumoniaandpyelo